24 EARLY ACCEPTANCE IN

Transcription

1 IN COMPLETE CLEFTS

2 24 EARLY ACCEPTANCE IN IN COMPLETE CLEFTS OFTEN IT HAS BEEN SAID EEAN INCOMPLETE CLEFT CAN BE MORE DIFFICULT THAN COMPLETE ONE YET WITH LESS TISSUE MISSING LESS NASAL DISTORTION AND BETTER MAXILLARY PLATFORM THIS NEED NOT BE THE CASE IF EFFICIENTLY DESIGNED THE END PRODUCT SHOULD APPROACH NORMALCY THE ROTATIONADVANCEMENT METHOD RECEIVED ALMOST IMMEDIATE ACCEPTANCE IN INCOMPLETE CLEFTS FIRST IT NOT ONLY EXCEEDED THE ACCOMPLISHMENTS OF THE OTHER METHODS BUT DID SO WITH GREATER ECONOMY OF TISSUE IT WAS THE ONLY METHOD THAT RATHER THAN EXCISE UTILIZED SIMONARTS BAND WHENTHERE WERE MESENCHYMAL ELEMENTS PRESENT SECOND THE EARLY DIAGRAMS AND PARTICULARLY THE DRAWINGS OF FRERET WERE AN EXCELLENT GUIDE TO HOW TO HANDLE INCOMPLETE CLEFTS AND WERE PARTLY RESPONSIBLE FOR THE EARLY ACCEPTANCE SEVERAL SURGEONS EXPRESSED THEIR PREFERENCE FOR THE ROTATIONADVANCEMENT IN INCOMPLETE CLEFTS CLIFF AND POOL STARTED PRECEDENT IF IT IS NECESSARY TO COMBINE THE LENGTH OF THE ZPLASTY WITH LENGTHENING OF ONE SIDE OF THE CENTRAL LIMB THIS CAN BE DONE BY ECCENTRIC LENGTHENING OF ONE OF THE FLAPS OF THE THIS MODIFICATION OF THE ZPLASTY IS THE BASIS FOR REPAIR AS OUTLINED BY DR MILLARD AND IS MOST USEFUL IN INCOMPLETE CLEFTS SINCE THE VERMILION OF FULL THICKNESS ON THE TWO SIDES IS USUALLY AT DIFFERENT LEVEL CONSISTENT WITH HIS PREDICTION ON INCOMPLETE CLEFTS ROBERT POOL HAS CONTINUED HIS USE OF THE ROTATION ADVANCEMENT AS 299

3 EXEMPLIFIED BY THE LOVELY CASE HE FORWARDED IN 1974 ROSS MUSGRAVE FROM THE UNIVERSITY OF PITTSBURGH IN PRE SENTATION TO THE AMERICAN CLEFT PALATE ASSOCIATION IN 1962 GAVE HIS OPINIONS IN AN ATTEMPT TO SAVE AS MUCH OF THE CUPIDS BOW AS POSSIBLE VARIOUS PROCEDURES TO INTRODUCE LATERAL TISSUE INTO THE DEFICIENT MEDIAL PORTION OF THE LIP HAVE BEEN DESIGNED FOR EXAMPLE THE INSERTION OF THE MAJOR PORTION OF THIS TISSUE INTO THE AREA JUST BELOW THE COLUMELLA HAS BEEN WELL DEMON ROSS A4USGRAVE STRATED BY MILLARD THIS PRODUCES TIGHTENING OF THE LIP IN THE UPPER RAS IN PORTION AND SOME FULLNESS OF THE LIP AT THE MUCOCUTANEOUS JUNCTION ESPECIALLY IN THE INCOMPLETE CLEFTS OUR EXPERIENCE THE MILLARD PROCEDURE IS PARTICULARLY RECOMMENDED FOR THOSE CLEFTS WHICH ARE SOMEWHAT MORE SEVERE THAN THE NOTCHING OR 44 GROOVING RV AND YET SOMEWHAT LESS THAN THE WIDE COMPLETE CLEFT LIP THIS 96 OPERATION PRODUCES NICELY CAMOUFLAGED SCAR IT ELEVATES THE FLOOR OF THE NOSTRIL AND IT REARRANGES THE COLUMELLA BASE PARTICULARLY ON THE CLEFT SIDE FOR THOSE INFANTS WHO HAVE FULL LIP WITH WELL DEMARCATED MUCOCUTANEOUS RIDGE AND FOR WHOMTHE CLEFT IS NOT QUITE COMPLETE ONE CAN PRODUCE WITH THIS METHOD MOST SATISFYING AND AESTHETICALLY CORRECT RESULT MUSGRAVE REPEATED THESE FEELINGS IN 1964 FOR CONVERSE AND TOLD ME ON THE SIDE THE ROTATIONADVANCEMENT GETS THE MOST WHISTLES FROM THE NURSES AT THE END OF THE OPERATION 300

4 CLAYTON DEHAAN FOR STARK IN 1968 JOINED CLIFFORD POOL AND MUSGRAVE THE MAJORITY OF INCOMPLETE CLEFTS PRESENT MUCH MOTE COMPLICATED PROBLEMS AND CALL FOR MORE SOPHISTICATED APPROACH MILLARD HAS REPAIR WHICH WE CONSIDER EXCELLENT FOR AN INCOMPLETE CLEFT TRIANGULAR FLAP IS SHIFTED FROM ONE LIP MARGIN TO THE OTHER BUT IN CONTRAST TO OTHER TECHNIQUES THE TISSUE IS SHIFTED AT AND BELOW THE NOSTRIL FLOOR SO THAT MINIMAL AMOUNT OF LIP TISSUE IS DISCARDED ADVANCING THE FLAP BENEATH THE COLUMELLA GIVES ADEQUATE LENGTH TO THE LIP AND THE WOUND IS CLOSED ALONG LINE CLOSELY SIMULATING THE NORMAL PHILTRAL RIDGE AT THE SAME TIME THE COLUMELLAR BASE IS ROTATED UPWARD AND THE FLARING ALA NASI IS DRAWN MEDIALLY THUS CREATING LONGER COLUMELLA AND NATURAL APPEARING NOSTRIL FLOOR AND SILL THIS REPAIR WHICH CLAYTON DEHAAN HAS YIELDED EXCELLENT RESULTS IS RELATIVELY SIMPLE TECHNICALLY AND DOES NOT RELY ON SET OF PREDETERMINED POINTS ANY ADJUSTMENTS REQUITED IN THE LENGTH OF THE FLAP CAN BE READILY MADE AN ADDITIONAL ADVANTAGE IS THAT SECONDARY REPAIR CAN BE ACCOMPLISHED BY SIMPLE REDUPLICATION WITH EXTENSION OF THE ORIGINAL INCISIONS EVEN SOME OF MY MOST WORTHY ANTAGONISTS SUCH AS DAVID DAVIES AND PETER RANDALL IT HAS BEEN RUMORED PREFER THE ROTA TIONADVANCEMENT METHOD FOR MANY OF THEIR INCOMPLETE CLEFTS RESIDENTS DO NOT SEEM TO FIND THE PROCEDURE DIFFICULT HERE IS CLEFT THAT WAS ROTATED AND ADVANCED BY MY FIRST RESIDENT PETER STOKLEY IN 1968 AND HIS RESULT AS SEEN FOUR YEARS LATER THE EASIEST OF ALL PROBABLY THE IDEAL GENERAL CATEGORY FOR ANY CLEFT LIP PROCEDURE IS AN INCOMPLETE CLEFT IN THE ADULT NEGRO WITH THE MORE MASSIVE 301

5 MUSCULATURE VOLUMINOUS VERMILION NATURAL NASAL FLATNESS AND RACIAL COLUMELLA SHORTNESS THEREFORE AS MOST SURGEONS ADMIT THE ROTATIONADVANCEMENT PRINCIPLE IS EASY IN INCOMPLETE CLEFTS IT IS LITTLE WONDER THAT REVELED IN ROTATING AND ADVANCING AT 30 MINUTES APIECE THE CLEFTS POURING OUT OF AN INLAND VALLEY ON THE ISLAND OF HAITI ALTHOUGH THESE PEOPLE WERE NEVER SEEN AGAIN THERE NEED BE NO CONCERN WITH SUCH FULLBODIED LABIAL STRUCTURES AND LESS HAUGHTY NASAL ASPIRATIONS AS THEY SAT WITH THEIR STITCHES AT THE END OF THE OPERATION SO SHALL THEY BE UNTIL THE END OF THEIR TIME AN EXCEPTION AUTIO WITH GENERAL ACCEPTANCE OF THE ROTATIONADVANCEMENT PROCEDURE FOR INCOMPLETE CLEFTS THERE WAS IN THE DOOR AND TEMPTATION NOT TO LOOK GIFT HORSE IN THE MOUTH BUT TO CLAIM ALL INCOMPLETE CLEFTS FOR THE RA METHOD YET LEST WE RUN LIKE STUPID SHEEP INTO THE SLAUGHTER PEN LET US BALK AND RECONSIDER JI 302

6 IN THE RARE MINIMAL CLEFT WHERE THE DISPLACEMENT OF NORMAL STRUCTURES IS NIL RADICAL ROTATION AND COMPLETE ADVANCEMENT MAY BE UNNECESSARY ANY EFFORT TO AVOID SKIN SCARRING MUST BE CONSIDERED CAREFULLY THE MINIMINI CLEFT TAKUYA ONIZUKA OF TOKYO IN MELBOURNE IN 1971 SUGGESTED CONSERVATIVE BUT INTRIGUING METHOD OF HANDLING THE MINIMAL CLEFT LIP WHERE SLIGHTLY WIDE NOSTRIL FLOOR AND VERMILION NOTCHING ARE THE DEFORMITIES NOTED HERE EXCEPT FOR LACK OF PHILTRUM COLUMN ON THE CLEFT SIDE THE SKIN IS INTACT AND SHOULD BE KEPT THAT WAY ONIZUKA NARROWS THE NOSTRIL FLOOR WITH AN EXCISION AND CORRECTS THE VERMILION PEAK WITH SMALL ZPLASTY HE THEN UNDERMINES THE LIP SKIN BETWEEN THESE TWO AREAS AND GATHERS IT INTO AN EXAGGERATED ROLL LIKE PHILTRUM COLUMN WITH TAKUYA ONIZUKA MATTRESS SUTURES II AS NOTED BY OHMORI THE LONGTERM RESULTS OF THIS GATHERING WILL BE OF INTEREST AS THERE IS TENDENCY FOR SCARS AND ROLLS TO FLATTEN IN TIME PARTICULARLY UNDER CONTINUOUS LATERAL PULL OF THE LIP MUSCLES AVOIDING SKIN SCAR IN THESE SMALL NOTCHES HAS ALWAYS BEEN FAVORITE HOPE OF MINE HUT AS YET HAVE NOT BEEN ABLE TO CORRECT ALL THE OTHER ASSOCIATED DISCREPANCIES WITHOUT VIOLATING THE SKIN THIS INDEED MAY PROVE TO BE THE ANSWER IN CERTAIN VERY MINOR CLEFTS IT IS IMPORTANT TO END WITH THIS NOTE IN ALL THE CLEFTS THAT HAVE TREATED SINCE 1954 ONLY TWO COULD BE CORRECTED WITHOUT SKIN INCISION ONE WAS VERMILION NOTCH WITH NO OTHER 303

7 DEFICIENCIES OR DISTORTIONS PRESENT THE OTHER WAS SLIGHT DEFI CIENCY OF THE ORBICULARIS ORIS MUSCLE APPEARING AS VERTICAL SKIN GROOVE WHICH WAS UNDERMINED FROM THE FLOOR OF THE NOSE AND FILLED WITH DERMAL GRAFT YET RECENTLY TREATED CLEFT LIP WHICH ALTHOUGH IT REQUIRED SKIN INCISIONS WAS CORRECTABLE WITHOUT ROTATION THE PATIENT WAS 35YEAROLD MAN WHO HAS SISTER REPORTED TO HAVE SIMILAR MICROFORM BUT THERE IS NO FAMILY HISTORY OF THE CLEFT ANOMALY IN HIS FAMILY INCLUDING HIS OWN FOUR CHILDREN HIS CUPIDS BOW BOTH COLUMNS OF THE PHILTRUM AND THE INTERVENING DIMPLE WERE IN NORMAL POSITION THE SKIN GROOVE LATERAL TO THE CLEFT SIDE PHILTRUM COLUMN REQUIRED SKIN EXCISION THE LATERAL LIP MUSCLE BULGE WAS DISSECTED AND ROTATED DOWN AND MEDIAL MUSCLE FLAP FROM THE AREA OF THE VERTICAL GROOVE WAS TRANSPOSED UP INTO THE ROTATION GAP IN THE MUSCLE THE INTERRUPTION OF THE MUCOCUTA NEOUS ROLL RIDGE WAS INTERDIGITATED THE FREE BORDER MUCOSAL DEFICIENCY WAS FILLED OUT WITH POSTERIOR VY ROLLDOWN THE FLARING ALA AND WIDE NOSTRIL FLOOR WERE CORRECTED BY CIR CUMALAR INCISION ITS MEDIAL ADVANCEMENT DENUDATION OF THE TIP OF THIS FLAP AND SUTURING IT TO THE SEPTUM AT THE NASAL SPINE THE OTHER NASAL DEFORMITIES REQUIRED RHINOPLASTY SUBMUCOUS RESECTION OF THE SEPTAL CARTILAGE WITH STRUT GRAFT TO THE TIP ALAR CARTILAGE REDUCTION ON THE NORMAL SIDE AND AN ONLAY ALAR CARTILAGE GRAFT ON THE CLEFT SIDE IT IS INTERESTING TO NOTE THE CORRECTION WHICH NECESSITATED ALL OTHER ASPECTS OF ROTATION ADVANCEMENT WITH REFINEMENTS EXTENSIONS AND ADJUNCTS STILL DID NOT REQUIRE ROTATION THIS IS INDEED RARE SITUATION II 304